LECTURE

Perspectives in Medical Education
9. Revisiting the Blueprintfor Reform of Medical Education in Japan
R. Harsha Rao1 and Kanchan H. Rao2

Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA
Departments of Medicine & Office of Admissions, University of Pittsburgh School of Medicine, Pennsylvania, USA
1

2(Received for publication on August 11, 2009)(Revised for publication on September 24, 2009)(Accepted for publication on November 19, 2009)

Reform of medical education at Keio University has been underway since 2003. We measure
the progress made since then in five specific categories that span fifteen recommendations
presented in our“Blueprint for Reform”at the outset of the effort. These are effectiveness ofleadership, curriculum reform, recognition of teaching, clinical competence, and comprehensive training in general internal medicine (GIM). First, effective leadership is being sustained
through a succession of Deans, although a potentially crippling loss of leadership in the Department of Medical Education must be offset through timely appointment. Second, curriculum reform is awaiting the implementation in 2012 of an integrated, organ system-based curriculum with an emphasis on ward clerkships, but the introduction of PBL has been delayed
indefinitely. Third, teaching is being recognized through the use of student feedback to reward
good teachers and through funds for six full-time equivalent salaries dedicated to medical education, but promotions still depend exclusively on research, without consideration of teachingability. Fourth, clinical skills training is still lacking, although enthusiasm for it seems to bebuilding, thanks to the presence on the wards of a (still miniscule) cadre of dedicated teachers.
Finally, exposure to GIM remains non-existent; however, visionary leadership in a newly-independent Emergency Department and the wide variety of medical problems seen there provide
a remarkable opportunity to craft a uniquely Japanese solution to the problem. The changes
implemented to date are impressive, and we remain enthusiastic about the future, even as we
recognize the magnitude of the task that lies ahead. (Keio J Med 59 (2) : 52－63, June 2010)

Keywords: medical education, clinical competence, curriculum, teaching, Japan
Introduction

ing aspects of this voyage has been a recurring theme involving the willingness of those in the field of medical
education at every location we visited in Japan to accept
the deficiencies in the system and to enthusiastically embrace the need for reform.
Nowhere has this enthusiasm been more apparent to us
than at the institution with which we have had the longest and most productive association: Keio University
School of Medicine in Tokyo, one of Japan’s premier institutions for medical education. The strength and durability of this association is reflected in the first four pa-

In a series of reflective papers based on our experiences over the past six years at different locations and in
disparate settings in Japan, we have documented the
problems that bedevil medical education in Japan. 1- 8
Looking back, we are conscious that a journey that started out as a voyage into the unknown has evolved into avoyage of discovery that has, in all humility, enriched,
informed and educated us in a way that we never imagined when we embarked upon it. One of the more amaz-

Reprint requests to: R. Harsha Rao, MD, FRCP, Department of Medicine, University of Pittsburgh School of Medicine, Room 580 Falk Medical Building,3601 Fifth Avenue, Pittsburgh PA 15213, USA, E-mail: rhrao@pitt.edu
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Keio J Med 2010; 59 (2): 52－63

pers in this series, which were devoted exclusively toobserving, analyzing, and critiquing the state of medical
education at Keio University, often with brutal candor.
So much so that some were moved to criticize that very
candor as being excessive or misplaced (i.e. a “misperception”).9
It is a criticism that may seem, at first glance, to bereasonable and deserved, particularly in the context of acountry like Japan, where courtesy is both renowned andrevered, and where, until relatively recently, the perspectives of outsiders were dismissed as being blind to therealities and traditions of Japan, and thus characterized,
quite accurately, as “misperceptions”. Thus, it is equallyreasonable, in that first glance, to conclude that ourharsh and unforgiving assessment of the state of medical
education at Keio University in 2003 might be a productof our inability, as quintessential outsiders, to understandthe uniquely Japanese constraints to reform. Add to thata reflexive and not unnatural desire of the criticized todismiss the harsh truth out of a dislike for facing reality
and the perception of unjustified harshness becomes understandable.
None of this, however, is applicable in the context of
our experiences at Keio –or, for that matter, at the otherlocations in Japan where we have made similar assessments.6, 7 In the first place, any careful reader of our papers will discern that we have taken great pains to place
our criticisms in the context of Japanese traditions andpractices. In the second, our criticisms were neither rejected nor resented, but welcomed and accepted by those
who might be in the best position to judge whether or
not they were appropriate or unfounded. This is particularly true of the authorities at Keio University, where theungrudging acceptance of our criticisms has held true
over six years and a succession of three different Deans,starting in 2003 with Professor Kitajima, continuingwith his successor, Professor Ikeda, up to and including
the current incumbent, Professor Suematsu. Dean Suematsu, in particular, has taken the reform process started
by Dean Kitajima a step further, infusing the effort witha new-found energy and advancing it into territory that
we ourselves had deemed impossible or impractical (aswe will outline later). We would humbly submit that,
had our criticisms been truly unjustified (or a misperception), we would not have the privilege, as we do now, of
continuing our ongoing involvement in the reform effort
at Keio, let alone of maintaining the enduring friendships we have developed there. We are, therefore, content that those in the best position to judge or be offended by our initial unforgiving critique view it as being appropriate and justified and our perspectives as being valid.
Our initial perspective in 2003 on the state of medical
education in Japan in general, and at Keio University
School of Medicine specifically, was the starting point
for this series of papers. That perspective continues to be53

informed and molded by our ongoing contacts and experiences in Japan, which are the basis for the overarchingcase we have made for the pressing need for reform inJapan.3, 4
One continuing theme in the evolution of our perspective –and the area for which we continue to reserve ourharshest criticism– is the virtual lack of interactive or
clinical teaching in Japan and the resultant lack of clinical skills in Japanese students and residents. It is manifest most tellingly in their inability, with rare exceptions,to take a minimally acceptable history or perform themost basic physical examination. It is no surprise, then,that they remain, for the most part, unable to engage ineven the simplest aspects of clinical decision-making or
problem resolution through deliberative reasoning.
While much has changed since our first visit, this inability still persists, in our minds, as the biggest deficiency
in Japanese medical education. It cries out for a remedy,
but no easy remedy is to be found. Yet, we see on thisvisit the first inkling of a possible answer to the cry, as
we will outline later.
The focus of this paper will be on what has changed
since our first visit to Keio in 2003. Like all its predecessors, the paper is based on a report we submitted to ourhosts upon the completion of our visit. Its primary objective is to place on record, in the same spirit of candor
and intellectual honesty of our earlier papers, the changes that we are now witnessing at Keio. A secondary objective is to place on record our own excitement and enthusiasm for the progress in the reform effort that is underway, without minimizing in any way the monumental
task that lies ahead.
Creating a Yardstick to Measure
the Progress of Reform
In order to document the individual reforms introduced to date at Keio since our first visit, and to measure
the progress that has been made since then, we need acredible yardstick against which success or failure canbe assessed and measured. For this purpose, we will
adapt a technique that has served us well in other such
evaluative exercises in this series (e.g. at the Muribushi
Project in Okinawa6 and at Teine Keijinkai Hospital in
Sapporo7). In both those instances, given that both programs were of very recent origin, we were able to locate
published source documents that identified their respective goals and objectives. Those self-determined criteria
were then used to create a unique yardstick for each program against which success in meeting their own goals
could be measured.
In the case of a long-established program like that at
Keio University School of Medicine, the absence of asimilar source document dictated the need to create avalid and credible alternative. We decided, therefore, touse our own earlier criticisms and, more specifically, the54

Rao RH and Rao KH: Progress of Reform in Medical Education at Keio University“Blueprint for Reform” that we developed for Keio, outlining the specific areas where change was most feasible
and would have the greatest impact.2 The recommendations enumerated in that document will be used to createa similar yardstick of success or failure for the reform effort at Keio.
Readers interested in the specific details relating toeach of those recommendations are directed to that earlier paper.2 Here, we simply present an overview sufficient to provide an understanding of the four steps
through which we create the yardstick that we will be
used to measure the progress of the reform effort.
❖ The First Step is to understand the two thematicallydistinct categories into which the fifteen individual
recommendations previously published in our earlier
paper2 are divided (readers are directed to the twin
Appendices of that earlier paper, if they wish to review the basis and justifications for those recommendations). Those two themes are recognizable, even if
they are not quite as explicitly defined, as the following:a. Recommendations to change the system of medical
education at both the undergraduate and graduatelevel through the specific measures, (i.e. changing
the way that medicine is taught at Keio);2b. Recommendations to change prevailing attitudes
toward medical education among the faculty at
Keio through the specific measures (i.e. changing
the way need for reform is perceived by students
and faculty at Keio).2❖ The Second Step is to formulate a framework for
documenting the changes that have been implemented at Keio University School of Medicine since 2003.
To do this, the fifteen individual recommendations
will be restated in more concise terms and reorganized according to the two themes above into a more
coherent frame of reference, as follows:a. Recommendations for Changing the System of Medical Education during➢ In Residency (Graduate Medical Education)i. Emphasize Active Learning
ii. Emphasize History and Physical exam skills
iii. Introduce a system of non-threatening, anonymous feedback
iv. Emphasize the importance and value of teaching by (i) requiring faculty accountability andresponsibility for teaching, and (ii) rewarding
teaching and teachers
v. Focus on providing GIM Training for Residents➢ In Medical School (Undergraduate Medical Education)
vi. Make the curriculum more interesting and interactive by(a) Introducing Problem Based Learning, starting in the 3rd yr preclinical courses in medical
school(b) Shortening the preclinical curriculum to increase time for clinical training, and(c) Introducing core courses on physical diagnosis for students(d) Reducing the emphasis on didactic teachingvii. Make the curriculum more integrated (i.e. organsystems-based rather than subject-based)b. Recommendations for Changing Prevailing Attitudes
at Keio
i. Establish a sense of urgency
ii. Form a Powerful Guiding Coalition at Keio
University
iii. Create a vision for change and communicatethat vision
iv. Empower students so that they become engines
for change
v. Develop clear strategies for Medical Student
Education by (i) recognizing teaching as a legitimate academic activity and an essential ingredient of academic life, and (ii) rewarding excellent teachers both academically and financiallyvi. Introduce a system for anonymous evaluation ofteachers by students
vii. Increase exposure to ER training, to make betteruse of the only location at Keio where broadbased (non-specialist) clinical care is practiced
viii. Provide training in Bedside Clinical Instruction
for existing faculty❖ The Third Step is to distill these fifteen individual
recommendations down to the five major categories
listed below:
1. Provide effective leadership {items 2(i), (ii), (iii)and (iv) above}
2. Reform the Medical School Curriculum to makeit both integrated and interactive{items 1(i), (vi),(vii), above}
3. Recognize teaching as being vital for medical education at both undergraduate and graduate levels{items 1(iii), (iv), and 2(v), (vi) above}
4. Make clinical competence a key component of
medical education for students, residents and faculty {items 1(ii), and 2(viii) above}
5. Emphasize a comprehensive understanding ofclinical problems through exposure to general internal medicine instead of the existing narrow, subspecialty-based clinical perspective {items 1(v),and 2(vii) above}❖ The Fourth and Final Step is to rewrite those fivecategories above in the form of five questions that
constitute a credible and comprehensive yardstick forKeio J Med 2010; 59 (2): 52－63

measuring the progress of the reform effort at Keio
University School of Medicine since 2003. They are
the headings of each section that follows, underwhich we will document the changes we have encountered, and what remains to be done, so that theanswers to those five questions, when taken together,will provide a comprehensive overview of the current
state of medical education at Keio (as of 2009).
1. How Effective is the Leadership at Keio University
School of Medicine?
Six years have passed since our first unremittingly
bleak assessment of the state of medical education at
Keio. Six years later, we can state categorically that thelandscape for medical education at Keio is so different
that we find it difficult to comprehend. For this, leadership must receive most of the credit.
i. Pace of reform: While the pace of reform remains
agonizingly slow on a larger scale, what has beenachieved to date is nothing short of astounding to us,
who have watched the effort evolve from its first, uncertain beginnings, and stutter through a series of fits andstarts, to now reach a point of self-sustaining momentum
that will, hopefully, gather speed in the years to come.
The changes that we will document individually below
are testament to this, reflecting directly on the quality
and effectiveness of the leaders of the reform effort initiated by Dean Kitajima and continued under Dean Ikeda.
However, it is under the leadership of Dean Suematsu
that we are seeing a ramping up of the reform effort because he has injected a fresh dose of enthusiasm and dynamism into the process.
The noticeable acceleration of the reform process during Professor Suematsu’s tenure as Dean is a key factor
in preventing the stagnation that would be inevitable had
the initial reform decisions taken by Dean Kitajima notbeen expanded and improved upon, as we will describe
below. A side effect of it is that it has both reinforced
our own interest in and re-invigorated our association
with the effort to reform medical education at Keio.
This enthusiasm is born from the realization that there
now exists an opportunity to extend the reform effort toareas that we hitherto thought to be neither feasible norpractical.
ii. Evidence of innovative leadership: One striking example of how the leadership at Keio University is set tochange the culture and challenge established tradition isin the way that candidates for medical school are selected. It has come as a very pleasant surprise to us that
Keio University is beginning to recognize the very real
limitations of the traditional selection process for admission to medical school in Japan.
On this visit, we conducted two sessions that addressed this very subject. Both were really well attended,
and at both there was a vigorous and healthy discussion

55

on the need to rethink the process through which candidates are selected for admission to Keio University
School of Medicine. The most interesting aspect of these
discussions was that they occurred in the context of presentations that focused on the meaning of “Professionalism” for physicians in Japan.
That there should be any discussion of such a subject
is in itself astounding, because Professionalism is a concept that is alien to the mission of Japanese medical
schools, where the focus remains exclusively on bookknowledge. It is a very welcome sign that faculty members at Keio should recognize that excellence as a physician transcends academic performance and that Professionalism is a concept that embodies so much more thanknowledge or intellectual ability.
Such innovative thinking provides further evidence of
the willingness of the leadership at Keio to confront suchdifficult issues and go against tradition to make changes
in the best interest of the institution. It also signals that
Keio may be ready to challenge the long-establishedJapanese tradition of measuring ability on book knowledge alone, whether it is in evaluating an establishedphysician or selecting a candidate for admission to medical school. If the latter process is reformed to include
other dimensions of excellence and achievement, it
would inevitably lead to the creation of a cadre of young
physicians who, as the beneficiaries of such progressive
thinking, may have a greater interest in nurturing andfurthering reform in the decades to come. After all, there
could be no better way of empowering students to become engines for future change in medical education(one of the key elements of our recommendations forleadership in our “Blueprint”) than to change their own
perception of what constitutes an “excellent” physician.
iii. Evidence of dynamic leadership: The recent creation of a School of Graduate Medicine is another example of “outside-the-box” thinking in leadership at Keio.
Its purpose is to provide full tuition scholarships for thebrightest young minds at Keio Medical School who decide to pursue a combined MD-PhD degree and dedicate
their lives to a career in research. Thus it codifies in aunique and distinctive manner the delineation of a career
track that is based on research potential and achievement.
At first glance, this may seem redundant since the only
career path to academic success in Japan is one that goes
through research. What is interesting about this move,
however, is something that is less obvious, but just as
definite. After all, if it codifies a career track to academic success for candidates who make an early commitment to research, it must codify, just as clearly, an alternative career track that is not necessarily dependent on
dedication to research. Thus this move might actuallyturn out to be the first step to recognizing that there
could be two separate academic career tracks.
We are very well aware that such a delineation of the

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Rao RH and Rao KH: Progress of Reform in Medical Education at Keio University

twin alternatives is still so subtle in even our minds as tobe no more than the most remote of possibilities at thispoint. Nevertheless, the fact that it is possible to contemplate such a future delineation of academic career tracks,
no matter how subtle it might be, is a first for Japan,
where only one track exists for academic success. One
can only hope that, with time and the maturation of the
School into a viable pipeline for true physician scientists
with impressive research credentials, the delineation willgo from remote possibility to reality. That would, indeed, be a truly pioneering development for medical education in Japan.
iv. Loss of leadership: Notwithstanding all the notable
positives since our first visit in 2003, there is one major
negative. It is the recent retirement of Professor Takahiro
Amano as Head of the Department of Medical Education. His departure has deprived the reform effort of atrue stalwart, an unflinching visionary who both fueled
and drove the reform effort from its outset. His absence,at this critical juncture, will be sorely felt. Only time willtell if the immense void left with Professor Amano’s retirement can be filled or if it will stall the reform effort.
Nonetheless, we remain optimistic about the future,for several reasons. In the first place, Professor Amano
will continue his association with Keio University in a
consultative capacity. This will hopefully provide a degree of continuity and with it a modicum of reassurance
that the reform effort will not die with his retirement.
Secondly, the interim appointment of a close personal
friend of his to the position allows him to be involved in
the process without treading on toes. Thirdly, the appointment of Dr Michito Hirakata to the Department ofMedical Education with a full-time commitment toteaching is a step in the right direction, although his relative inexperience in the field means that he will face avery steep learning curve while on the job! Finally, thepersonal involvement of Dean Suematsu in the reform
effort mitigates this otherwise grievous body blow to theeffort. He is the Principal Investigator on a multimillion
yen grant to implement competency assessment duringresidency training. This should assure that he will continue to maintain a hands-on interest in the reform effort.
Summary of the Current State of Leadership Compared
to 2003:
What has changed: Nothing, in the best possible senseof the word; it remains dynamic at the top and highlycommitted to building upon and expanding the reform
process. Thus, the commitment to reform appears to beunchanged in a very positive sense at the level of Dean.
However, the retirement of Professor Amano at the Department of Medical Education remains a serious concern. His shoes will be extremely hard if not impossible
to fill.
What remains to be done: The void in leadership in
the Department of Medical Education must be filled

quickly and effectively with a permanent replacement of
the current interim arrangement. Professor Amano’s retirement comes at the worst possible time, when the reform effort is reaching a crucial juncture. His continued
involvement in a consultative capacity is important, but
it could be so much better if he is awarded Emeritus status. Even though he is eminently qualified for it, considering his immense contributions, he cannot receive it under Keio University’s rigid rule requiring a 15 year minimum tenure as full Professor for Emeritus status. A seismic change in University policy is called for, in recognition of the fact that the quality of contributions, not time,should determine qualification for such an honor –not tomention the continued best interests of the University itself!
2. What is the Current State of Curriculum Reformat Keio University School of Medicine?
In 2009, the Keio University medical school curriculum is exactly the same as it was in 2003. This seemingly bleak assessment hides the truth, which is that the two
major suggested reforms of the medical school curriculum in our Blueprint have been duly considered and one
is close to being implemented. Specifically, two vitally
important decisions have been taken to reform the medical school curriculum at Keio: to develop and implement
an Integrated Curriculum, and to incorporate Problembased Learning (PBL) into student education at an undetermined later date, once the integrated curriculum is up
and running.
i. The Introduction of an Integrated Curriculum is closer of the two to being a reality. According to Professor
Amano, who has almost single-handedly shepherded thisinitiative through a long and painful gestation and no
doubt against deep and vociferous opposition from entrenched interests, an organ system-based curriculum isscheduled for implementation at Keio with the class of
2012. What is particularly fascinating is that the new
curriculum includes a provision for shortening the preclinical years much as we have recommended,2, 5 so thatclinical studies could begin as early as the fourth year of
the six year curriculum, i.e. three years of clinical training, instead of two. A proposal is even on the table thatthe last (sixth) year should be devoted entirely to ward
clerkships without didactic lectures. One can only hopethat these clerkships will provide students with the needed hands-on clinical training in the wards, much like“acting internships” and senior year rotations in the major specialties do for fourth year students in the US.
A major reason that the new curriculum initiative hasadvanced to the point where it may become reality is theforceful backing it has received from the current Dean.
He has argued with vigor for its implementation, securing tentative agreement for the envisioned changes atboth the University level and the Chairs Committee. ItKeio J Med 2010; 59 (2): 52－63

remains to be seen whether or not these tentative agreements translate into implementation, particularly withthe retirement of Professor Amano, but both he andDean Suematsu have assured us that it will happen.
ii. The Inclusion of Problem Based Learning in the
Curriculum, by contrast, has hit a major roadblock, resulting in a deliberate decision only to incorporate it “atsome point in the future”. The roadblock has to do with
two factors. The first is the lack of teachers with theknowledge and skill to either (a) develop PBL exercisesor (b) conduct and facilitate them. The former problem
can be solved by importing pre-prepared PBL exercises
from any of several reputable sources; the latter cannotbe.
The second factor is a surprising lack of appreciationof the purpose of PBL on the part of both the faculty andthe students–an astonishing fact that was admitted to me
by none other than Professor Amano himself. We weredismayed to learn this, because it went against everything we had come to believe about the applicability andefficacy of the PBL method in the Japanese context. It isa belief that stems from our personal experience conducting multiple PBL exercises on previous visits to
Keio. The purpose of these was explicit: to demonstrate
its efficacy in the Japanese setting.
Our sense was that we fulfilled that purpose every
time, including one memorable occasion when one of us(RHR) facilitated a PBL resolution session in Japanese
as a demonstration exercise before an audience of over
40 faculty members and an equal number of students,
despite a complete inability to communicate in that language (the handouts, fortunately, were in English). 4 It
was particularly effective because it demonstrated as
nothing else could to the observing faculty (who are notorious for turning every teaching exercise into a didactic session) that the proper role of the PBL facilitator isto stay silent unless absolutely necessary.
Since these exercises were so unquestionably successful, we felt they would cement in the minds of both thestudents and the faculty the value and the intent of problem-based learning. Unfortunately, that belief has been
confounded by the reality of the system of education in
Japan, not just medical education. It is not that we were
unaware of this reality; it is just that we truly expected
the excitement we sensed in Japanese students for PBL
would trump that reality.
The reality is, in fact, the opposite of our naïve expectation. According to Professor Amano, the all-pervasive
culture of by-rote learning and an obsession with gradeson the part of both teacher and taught, to the exclusionof all else, will almost certainly lead to a flourishing underground cottage industry that offers self-perpetuating
PBL “solutions” for sale by seniors to juniors who wantto save themselves the time and effort of developing
learning objectives, researching the answers and creating
handouts. The availability of such “solutions”, of course,

57

will completely defeat the purpose of PBL, which is toencourage self study and develop problem-solving skills.
For this reason, Professor Amano has decided –wisely, it
would seem!– to postpone the introduction of PBL to an
undetermined later time.
As practical as that decision is, it is a great disappointment for us, particularly in the context of our own experiences with conducting PBLs with selected groups ofstudents at Keio University School of Medicine. Thesesessions have been so uniformly successful, even exhilarating, for us as teachers, that it is difficult to accept thedecision to postpone their introduction, even as we acknowledge the validity of the reasons behind the decision.
Summary of the Current State of Curriculum Reformat Keio Compared to 2003:
What has changed: Of the two major recommendations we made (Integration of the Curriculum, and Incorporation of Problem Based Learning), the first is close tobeing implemented. The decision to implement a new
integrated (organ-system-based) curriculum in 2012 hasbeen taken, and it is in the process of being developed.
A major plus would be the increased emphasis on clinical training with a concomitant decrease in time allottedto preclinical education.
What remains to be done: The tentative date for implementation of the new curriculum is still three years in
the future. It remains to be seen if and when it is actually
implemented, but if it is, Keio will have taken a truly impressive step towards changing the face of medical education there. The prospect of losing momentum becauseof the retirement of Professor Amano is very real, so thepersonal involvement of Dean Suematsu in the process
could be vital for assuring that this does not happen. The
incorporation of PBL in the curriculum, however, ispostponed, with no foreseeable implementation date at
this time. Given the practical reasons for the deferment,
we believe that, for the time being, the introduction of an
integrated curriculum is the greater achievement. Its emphasis on clinical training instead of by-rote memorization of book knowledge will hopefully change attitudes
enough to allow for PBL implementation at a later date.
3. Has There Been any Progress towards Recognizing
the Importance of Teachers and Teaching at Keio
University School of Medicine?
The major changes in Undergraduate Medical Education that we are now witnessing have also coincided withanother change that we never thought possible: the firststeps are being taken to recognize the importance ofteaching at Keio. The change is more attitudinal thanconcrete, and we do not delude ourselves that teaching iseven remotely close to being recognized as being the academic co-equal of research. However, the shift towards

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Rao RH and Rao KH: Progress of Reform in Medical Education at Keio University

recognizing teaching as a valid and valuable academic
activity is now underway.
i. Promotions Policy: In the Blueprint we submitted,2
we identified the Promotions Policy at Keio as one of
the areas that needed major changes if the reform of
medical education was to succeed. Specifically, it wasrecommended that the Dean set aside funds to support
faculty members who dedicate their careers to teaching
medical students and residents. The current Dean was at
the time the Chairman of the Promotions Committee andhe expressed a very palpable enthusiasm for the idea thata separate career track be created for teachers to provide
promotions and rewards through a system that was insulated from the all-pervasive pressure to conduct researchor perish academically.
Despite this, the truth of the matter is that there is noconcrete change in 2009 compared to 2003. Research isstill the only criterion for academic advancement, andquantity or quality of teaching does not figure in theequation–not even as a minimum requirement–for promotion at any level in the medical school. Even those
who are given salaried appointments in the Departmentof Medical Education are required to get grants to support their academic activities in the Department if they
are to have any hope of being promoted.
ii. Recognizing the Importance of Teachers: The firststep in this direction was taken by Dean Kitajima who
provided funds to support the salaries of two junior faculty members in the Department of Medical Education.
Their responsibilities were to provide students with clinical instruction at the bedside. Under the current leadership, there has been a tripling of the number of salaried
positions in the Department of Medical Education fromtwo to six. As far as the authors are aware, Keio University School of Medicine may be unique in Japan with regard to this degree of commitment of resources to medical education.
iii. Changing Faculty Attitudes Towards Teaching: At
its most visceral level, faculty attitudes to teaching will
not change materially until its importance for promotion
is acknowledged and recognized. Notwithstanding this,we have witnessed a subtle but distinct shift in faculty
attitudes towards teaching! This shows itself in the enthusiasm for teaching among those of the younger faculty members at Keio with whom we had the opportunity
to interact. Their enthusiasm for teaching is a most surprising development, which is enough to give eternal optimists like us hope, even though they are still in a verysmall minority.
It may just be that the younger faculty members have
not yet had the time to think through and establish their“real” priorities. It may even be that their attitudes have
not yet been hardened by the cynical realities of Japanese academic life, with its unremitting focus on research for academic advancement. However, it alsomeans that the authorities at Keio University may now

be in a position to strengthen the future of teaching at
Keio in a way that was never possible before, if they arewilling to seize the moment and exploit the window ofopportunity it presents.
The opportunity to which we refer has to do with thebudding interest in teaching that we see at Keio, and its
direct correlate in the nascent “youth movement”. This isbecause any real change in established culture and attitudes requires the infusion of new (and younger) faces,with new ideas and new approaches. After all, entrenched interests, ideas and traditions are bound to reflexively oppose any change in the status quo, becausechange will inevitably threaten the existing structure.
New attitudes, if cultivated appropriately and given timeto grow, can sweep away old ideas and outdated traditions, because youth has the great advantage of time on
its side! In other words, by fostering the interest ofyounger faculty in teaching, the leadership at Keio cancreate an unstoppable momentum for change that will
outlive and overwhelm the resistance from the old guard.
To do that, however, the cynical reality of academic
life at Keio (that research is the only worthwhile academic pursuit) must be altered by recognizing teachingas a creditable alternative criterion for academic advancement.
iv. Anonymous Evaluation and Feedback: This is one
aspect that seems to be lagging in the otherwise commendable first steps that are being taken towards recognizing teaching as a viable and worthwhile academic
pursuit at Keio. This is shown by the fact that there isvery little appreciation of the need for anonymous student feedback to evaluate teaching skills. According toour discussions with Professor Amano, only two Departments are collecting and/or using truly anonymous feedback from students to evaluate teachers and teaching:
Pediatrics and Emergency Medicine. Both of these departments are blessed by the presence of forward-thinking and charismatic Chairmen who value medical education and thus use the information as part of their annual
evaluation of faculty performance. However, it is conspicuous by its absence in other departments.
We have impressed on Dean Suematsu the need for aschool-wide policy that calls for all departments to follow the lead of these two departments, because thatwould be the only way to assure that teaching will betaken seriously. In addition, the policy needs to bechanged at the University level as well to include thestudents’ evaluation of faculty as one aspect of assessing
faculty performance.
v. Rewarding Teaching in other ways: This is anotherarea of where we see discernable improvement since2003. The Dean and the Department of Medical Education have established an annual Teaching Award for thebest teacher in each of the last 3 years of medical school:
the fourth (preclinical), fifth (junior clinical) and sixth(senior clinical) years. Selection is based on a poll of theKeio J Med 2010; 59 (2): 52－63

students, who are asked to rank all the teachers they
have encountered in the year, after which there is a runoff poll of the top three nominees. The winner in eachyear receives an award at an annual banquet hosted forthe faculty by the Dean.
Summary of the Current State of Teaching at Keio
Compared to 2003:
What has changed: The emerging signs that teachingat Keio will become a rewarding activity are truly
groundbreaking for Japanese medical education.
What remains to be done: The fact that it is still notconcretely rewarded at the time of promotion is a major
constraint to its appreciation by faculty as being worthwhile. Promotions Policy remains unchanged at thehighest level, which is unfortunate. Thus, there is still no
mechanism to incorporate teaching abilities or student
feedback of faculty in the overall evaluation of individual faculty for promotion. We recognize the difficulty inchanging University rules, over which the Dean has little
control, but the fact remains that until such time thatthose change, faculty attitudes towards teaching are unlikely to change.
4. Is Clinical Competence a Key Component of Medical
Education at Keio University School of Medicine?
The lack of the most basic clinical skills among students and residents is as legendary as it is almost universal in Japan. Not surprisingly, clinical competence is oneof the two areas for which we have reserved our most severe criticisms in the past (the other, which is the lack of
exposure to GIM, is discussed below).3, 4 Therefore, it is
only appropriate that we revisit our earlier criticisms before we begin to evaluate whether or not any progresshas been made in this area since 2003,
The gist of those is (i) that Japanese medical education
remains disinterested in clinical skills training becauseof the heavy technological emphasis in healthcare practice (a lack of clinical interest), (ii) that there is a striking
absence of practitioners who appreciate and are skilled
in clinical evaluation and decision-making (a lack ofclinical teachers), and (iii) that these deficiencies aremost glaringly evident during residency training, because of its overwhelming emphasis on subspecialty
training (a lack of clinical training for residents). We will
re-examine those criticisms individually to see if they remain as valid today as they did in 2003, or if things havechanged.
i. Clinical Interest: In this regard, we are pleased toreport that there has been a change, but that change ismore subjective than objective. By that we mean that it
is our perception that there is an increase in enthusiasm
for acquiring clinical skills, but we have no way of verifying, let alone quantifying it, based on concrete evidence.

59

Nevertheless, our perception is that there is an unmistakable and new-found –and much-needed!– increase inenthusiasm for clinical learning among the students withwhom we interacted. This was amply demonstrated inseveral ways on this visit at a “bedside” teaching session
in a classroom conducted by one of us (RHR) to demonstrate History-taking and Physical Examination techniques, using a student volunteer.
In the first place, the session was attended by approximately 35 senior students (5th and 6th year), a numberthat is impressive beyond description, because it is atleast four times greater than the attendance at any otherinteractive session either of us has conducted at Keio,whether at the bedside or for PBL! Second, every one of
the attendees stayed for the entire time, despite the factthat it lasted for a full three hours. Third, none of the attendees fell asleep, in contrast to previous observations
made by us at didactic sessions attended by similar numbers of students, when at least half the class was observed to be asleep at any given time.2
There was something else, too, to add to their attendance in previously unheard-of numbers and the palpable excitement they exhibited, and this was the moststunning of all. It was their willingness to not only answer questions, but to actually ask questions themselves,
instead of simply sitting silent like automatons, neither
asking nor answering questions. It was delightful beyond
description for us to see the participants to abandon thisnotorious characteristic of the Japanese student, which
we have termed “passivity” in the past, 1-3, 6 and which
we have hitherto found to be all-pervasive and all-encompassing. The enthusiasm and excitement that they
displayed for learning H&P skills is a truly significant
development because it is a key element for making clinical thinking (“Rinsho Shikokate”) and clinical decisionmaking (“Rinsho Suiron”) an integral part of student
training at Keio.
ii. Clinical teachers: One major contributor to theawakening of interest and associated abandonment ofpassivity is the presence on the wards of a still minisculecadre of faculty members who are truly dedicated to thecause of teaching. One of these is Dr. TomoharuYajima.
He occupies a fully funded teaching position in the Division of Gastroenterology and is a constant and indefatigable presence on the wards. I have rounded with him in
the past and have found him to be committed to bothclinical medicine and bedside teaching. Students assigned to his ward are surprisingly interested in clinicaltraining, of which one small, but telling example is theiroccasional willingness to even perform a digital rectal
examination. The significance of this will not escapethose who are familiar with the abhorrence with which
the average Japanese citizen, whether physician or patient, views the very thought of performing or being subjected to such an act!
For all of these reasons, it is safe to say that this is the

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Rao RH and Rao KH: Progress of Reform in Medical Education at Keio University

first time that we have sensed this degree of excitement
for clinical bedside learning (as opposed to book learning), and it seems as if the “contagion” is beginning to
spread through the student body, instead of being restricted to only the handful of those who might be considering training in the US, as it has on our trips in thepast.1, 4 The efforts of the leadership to encourage teaching and to pay for it (through salary support, even if not
yet through promotions) must be directly linked to thistremendous change in student behavior.
It is unclear, however, how much hands-on clinical instruction the students receive across the board in otherspecialties and other wards. One can only hope that thegrowth of these emerging signs of clinical interest is fostered by selecting more such faculty members in the Department of Medicine.
We have recommended in the past that salary support
for at least one FTE be provided to cover the teachingactivities of one member of the faculty in each division,
whether this is devoted to a single attending, like Dr. Yajima (or Dr. Toru Sato of Cardiology in the past, prior to
his recent departure), or divided between different attending faculty who collectively share the burden over
the week. This would be essential for the appreciation ofclinical learning to be fostered among the students andfor the importance of clinical teaching to be impressed
upon the faculty.
iii. Clinical training for Residents: This is one area ofimpending change that might be even more significant(if that is possible!) than the previous ones we havementioned. For the first time in the past 6 years, we
sense that there is an opportunity to make truly meaningful changes in an area of medical education which we
had given up as a “lost cause”: residency training (alsocalled “Graduate Medical Education” or GME in the
US).
Readers of earlier papers in this series will recall that
this aspect of medical education at Keio was one that we
did not have much hope of reforming.1, 2 The reason forthis was our belief that it could never change as long as
residents remained under the iron-fisted control of the
Department Chairs. After all, it would be impossible toenforce uniform standards of training for residents
across different departments if training remained completely under the internal control of departmental Chairs.
Reform was made even more impossible by the fact that
residents themselves accepted their inferior status asbonded servants who should be grateful simply for theopportunity to apprentice with their mentors.
We have also since learned that the reason for it is thatmost residents, if not all of them, occupied “non-salaried” positions, receiving nothing but a small stipend
that was given at the discretion of the Chair. Yet, theseresidents were shown on the books as being salaried, as
required under the rules established by the Ministry of
Health. (Parenthetically, to those familiar with the all-en-compassing oversight and control of a GME Office forevery residency program in the US, this would be unimaginable in the modern day, but that is neither here
nor there.) What is relevant is that the budgetary allocation of the funds for residency training from the Dean’s
office left it to the individual Chairmen to distributethese funds according to their departmental priorities.
When one understands that, in Japan, academic priorities
give pre-eminence to research at all costs, it is not surprising that the bulk of these funds never reached the intended recipients. When one factors in the absence inJapan of any oversight mechanism like the ACGME,
even with the recent introduction of a mandatory twoyear residency for all medical graduates, such practices
become inevitable.
One begins to comprehend, in the light of the foregoing, why residents would be treated by faculty as being
little more than the equivalent of “slave labor” –and justas inevitable that the residents themselves would resign
themselves to being such! My own experiences on thewards at Keio are a testament to the pernicious prevalence of these attitudes in the past, as I have described inearlier papers, including one memorable occasion whena hapless resident was reduced by his mentor to tears in
my presence for not knowing the answer to a question.1
Such attitudes and traditions, in our mind, presented aformidable challenge to the task of reforming GME,
which is why we resolutely stayed away from making
any suggestions for drastic change in this area of medical education. In particular, it was our feeling that thefirst step towards any meaningful reform of GME would
be for these young doctors to be liberated from the control exerted by their mentors. To us, that was unimaginable in the Japanese academic medical structure, with its“ikyoku koza” system steeped in feudal traditions.1 0 Add
to this the fiscal constraints we described above, and ourfatalistic acceptance of the impossibility of reform becomes understandable.
To our astonishment, however, the authorities at Keiohave proven us wrong, thanks to their willingness to
confront and change such age-old traditions. Through atruly audacious move, that we understand was Dean
Suematsu’s own brainchild, the budgetary allocation offunds for residents’ salaries is no longer assigned to theindividual Chairmen, but is administered via an independent mechanism that is controlled through the Dean’s office. (Parenthetically, once more, for those familiar with
the US system, one begins to see the first nascent signsof a GME office taking shape in this move away fromdepartmental control to independent control of residency
funds.)
Thanks to this fundamental change (which took a lotof courage to push through) reform of GME is now not
only possible, but might even succeed. In one swift
stroke, it has liberated the entire GME system andopened up a fantastic opportunity for meaningful reform.

Keio J Med 2010; 59 (2): 52－63

In this regard, even more importantly, the Dean’s own
interest in “competency-based residency training” (asnoted above, he is the recipient of a large grant to fundthis) could make the reform of GME at Keio and, by extension, in Japan more than just an impossible dream.
The appointment of Dr. Michito Hirakata to lead the effort in the Department of Medical Education is yet another bold move that exemplifies the forward-thinking
and anticipatory approach to reform that we have seen
consistently at Keio University School of Medicine. If
this should come to pass, then Keio could become a true
pioneer in the field of GME in Japan, particularly if apractical and acceptable method is actually created forassessing the GME competencies in the Japanese context.
Summary of the Current State of Teaching at Keio
Compared to 2003:
What has changed: First, the burgeoning interest
among students in clinical skills training is a welcome
development which can only be attributed to the appointment of clinical teachers on the wards. Second, theliberation of the residents from the fiscal control of their
mentors is as revolutionary as it is stunning.
What remains to be done: Both of the changes described above present an amazing opportunity to reformthe structure and quality of GME at Keio and, by extension, for Keio University to become a true pioneer of
medical education in Japan. In both these areas, the leadership at Keio has demonstrated a willingness to challenge dogma and tradition with solutions that are practical and achievable in the Japanese context. These areclearly, just the first steps, and it will be the work ofbuilding on these initial steps that will determine if Keiois in the vanguard of the clinical reform movement.
However, the fact that the initial work has been donemeans that the next steps will be that much easier totake. What is astonishing is that student interest should
be increasing despite the desperately thin resources thatare available. These resources need to be expanded
quickly, because one can only imagine what might happen if there is any increase in number of dedicatedteachers on the wards.
5. Is There an Emphasis on Teaching Students a
Comprehensive Understanding of Clinical Problems at Keio University School of Medicine?
The complete lack of exposure to GIM is the second
area, other than the lack of clinical training and teaching,
for which we have reserved our severest criticism in our
initial assessments of the state of medical education at
Keio.1, 2 We have described the background and consequences of this lack in great depth in an earlier paper, so
we will not revisit those here.3 What is relevant is that
nothing has changed in this regard, simply because there61

is no GIM department at Keio. This remains a crippling
constraint preventing students from developing thebroad perspective on clinical decision-making and theoverarching understanding of clinical problems that only
generalists possess. As others also have noted,11 even theso-called “internal medicine” exposure that medical
graduates receive as part of their 2 year mandatory residency training is really nothing more than a string of
successive subspecialty rotations. These are ostensibly
designed to cover all the individual parts of “general”
medicine but cannot provide the overarching perspectiveof the patient as a whole that is so lacking.
We are fully aware that this is not unique to Keio University School of Medicine. We have bemoaned the lackof trained practitioners of GIM across Japan, extending
from Tokyo1- 4 to the far north (Sapporo7) and the extreme south (Okinawa6), all from personal experience.
We have also verified that it encompasses virtually allparts in between, according to the testimony of innumerable physicians from different parts of the country towhom we have spoken, confirming similar observations
by others.1 2, 1 3 Obviously, this is a lack that will not be
filled in a lifetime, if ever, given the widespread societal
disdain of non-specialists in Japanese, and the inferior
status that is accorded by the Japanese medical fraternity
to those who choose to become generalists. Just as obviously, the solution to this seemingly intractable problem has to be found within those same uniquely Japanese constraints that make it so intractable.
This was the thinking that underlay our recommendation in our “Blueprint” that Keio University should use
the undoubted strength of its Emergency Department(ED) to provide students with the broad perspective thatthey so desperately need. The background for this recommendation bears revisiting, because it is through thismechanism that Keio University could find the solutionthat Japanese medical education needs so desperately.
The ED at Keio is the ideal place to give students andresidents a broad perspective of clinical problems (andthe comprehensive understanding that only generalists
can provide) because of the following reasons, someunique to Japan, others unique to Keio:i. ED doctors are the only physicians who have anything resembling a broad perspective of medicine among
the otherwise terminally super-specialized medical fraternity in Japan.
ii. ED doctors at Keio actually admit patients to what
can only be described as an “acute medicine service” except that it is overseen by ED doctors (i.e. they are responsible for post-ED inpatient care in an ED ward).
iii. ED doctors act as attending physicians on patients
admitted to the ED ward, overseeing all aspects of care,and thus function as the equivalent to hospitalists on this“acute medicine service”.
iv. The acuteness of the inpatient problems they treat
means that they also function as intensivists!

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Rao RH and Rao KH: Progress of Reform in Medical Education at Keio University

v. The breadth of acute problems they encounter andmanage means that they also function as generalists. In
fact, the list spans the whole spectrum of medicine, notjust internal medicine, but also includes surgery, trauma,
gynecology, obstetrics... the list goes on. For instance,
we recall seeing a case of a Acute Spinal Subdural Abscess in the ED ward on one trip, which would properly
belong on a Neurosurgical ward in many other countries.
Yet, the management was being overseen capably by the
ED team.
vi. The ED is the only place where trainees can escapethe strangle-hold that the “super-specialist” mindset hason their training (and thinking).
vii. With an ED rotation being mandatory for both students and residents, the relatively brief stints spent by
students and residents in the ED constitue the only timethey will receive the crucial “broad-based” clinical perspective that is so deficient in Japanese medical education. Thus, the ED rotation, to our way of thinking, outweighs the importance of any other by several-fold (although this may be unique to Keio, as we will describe
below). In that sense, ED doctors at Keio fulfill theteaching role that is traditionally filled by internists in
the US!
Add to these, the very happy convergence of two
events, and one senses that Keio may be on the verge of
stumbling upon that uniquely Japanese solution that is so
desperately needed. One is the appointment of Professor
Shingo Hori as Chairman of an independent Departmentof Emergency Medicine. The other is a statement that
Professor Hori made during a meeting with us to discuss
medical education, that he was determined to “make the
ED the place where students and residents receive thebest teaching and training of any department at Keio”.
The significance of this was not lost on us, because
Professor Hori is someone who we identified very early
as a visionary with a real dedication to teaching.1 Therefore, it was particularly gratifying to us that a follow-up
question, based on the seven points highlighted above,
evoked Professor Hori’s eager agreement that his department was ideally suited to fulfilling the multiple roles of“generalist”, “intensivist” and provider of broad andcomprehensive clinical perspectives across the spectrumof medicine.
This is just the kind of uniquely Japanese solution thatis needed to change the complexion of medical education in Keio University and, by extension, Japan. For
this to happen, however, the leadership at Keio must acknowledge that the current two-week rotations for students and residents in the ED are pathetically inadequate
for the purpose. We have recommended to Professor
Hori that, at the very minimum, there should be an ER
rotation of one month in each of the two clinical years inmedical school and the two-year mandatory residency
period. In fact, to do real justice to the need, two monthrotations would be ideal. However, we are also conscious that the faculty resources available to Professor
Hori are limited, which is why we recommend the expansion of the single two week rotation to two onemonth rotations. It will be up to Dean Suematsu to makethe expansion of the faculty contingent in the ED a priority for the future of medical education at Keio University School of Medicine.
Summary of the Current State of GIM Training at Keio
Compared to 2003:
What has changed: Not much, to this point, which is
the unfortunate truth. However, as we have describedabove, recent events relating to the leadership at the Department of Emergency Medicine mean that Keio University has a tremendous opportunity to craft a uniquely
Japanese solution to the twin problems of providing boththe broad perspective of clinical problems and the comprehensive approach that is the hallmark of the generalist.
What remains to be done: It is vital that exposure to
Emergency Medicine be increased as an effective alternative to GIM, taking advantage of the unique featuresof Keio’s Department of Emergency Medicine. For thisto happen, though, ED ward rotations must be expanded
to one month in each clinical year of medical school andresidency. Furthermore, resources must be provided in
the ED through salary support for faculty who will carry
the teaching load.
Conclusion
We have made an effort to measure the progress thathas been made in reforming medical education at Keio
since 2003 using the most difficult yardstick we could
muster: our own brutally honest criticism of the state of
medical education as we found it then, together with thesteps we felt had to be taken to correct the defects we
encountered. By this yardstick, the changes that have occurred can only be described as surprising and significant. This characterization is not meant to minimize themagnitude of the task that remains to be completed; thatis as large as it is daunting. It is an effort on our part tooffer praise in the same spirit of honesty with which weoffered the earlier criticism, and with the same disbelief!
In other words, just as we could scarcely believe how
bad things were at the time, we can state with equal certainty that we would scarcely have believed that six
years later such a seismic shift would have occurred. It isa tribute to the farsightedness of the leadership at Keio
University School of Medicine that this has occurred.
Looked at another way, our own bullishness with regard to the future of the reform effort is an excellent alternative measure of the progress that has occurred in thepast six years. It is reflected in the quality and durabilityof the relationship we have maintained with those in-Keio J Med 2010; 59 (2): 52－63

volved in the effort, considering that those ties were first
formed under uncertain, even threatening circumstances,and with no assurance that anything would ever come ofit, given the harshness of our assessment. Events havesince proved that one thing, however, was never uncertain. It was the dynamism shown by all those involved inleading this effort. From the very outset, we were impressed by this characteristic as much as we were astonished by the apparent willingness to break the mold of
tradition. Just as creditable was the intellectual honesty
displayed in accepting, without the slightest trace of resentment or defensiveness, our withering critique of thestate of medical education at Keio as we encountered it
in 2003.
We have detailed above a factual account of the progress that has been made, by using an unforgiving yardstick created from that very critique. What is particularly
striking, as we look back upon the events that have unfolded over the past six years of this association, is thefact that the major points in our “Blueprint for Reform”
have been duly considered by the very people who might
be most likely to be offended by the criticism, and manyare in the process of being implemented. Finally, andmost gratifying of all from our personal perspective, isthat our ongoing association with the reform effort,
through repeated annual invitations from successive
Deans to visit Keio, affirms the validity of our criticisms. It also confirms that the reform effort not only
survives but thrives. As an aside, one of the happier outcomes of the amount of progress that has been made at
Keio since our first visit is that it relieves us of the unfounded charge that our criticism was, at best, misplacedor a misperception, and at worst, unfounded and unjust.
Subsequent events, as we have recorded above, have
proven that all of our early intuitive assessments werecorrect, and that the future of reform at Keio Medical

63

School is assured, thanks to the continued efforts of
those who have inherited the mantle of leadership there.
That leadership at this crucial stage is vital to maintaining Keio University’s position as a premier institution
for medical education in Japan.
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